ACHILLES BURSITIS – PHYSIOTHERAPY PERSPECTIVE

INTRODUCTION

A bursa is a sac of synovial fluid, rich in protein and collagen. These fluid-filled sacs form in areas where 2 surfaces in your body – most often where a bone and tendon or a bone and muscle – rub together during movement.

There are 2 bursae that surround the Achilles Tendon to protect it from friction –

  1. The retrocalcaneal bursa lies between the tendon and the back, or posterior surface, of the heel bone (calcaneus). This is a “true” bursa that is present from birth. It acts as a cushion between these two structures to protect the tendon from friction against the heel bone.
  2. The larger subcutaneous calcaneal bursa lies over top of the tendon at the lower part of the heel where the tendon joins to the heel bone. It is not found in everyone and for this reason is termed an “adventitious” bursa.
achilles tendon

When pressure or friction is too high, excess fluid can build up in the bursa sac and/or the lining of the sac can thicken, causing inflammation. When an achilles bursa becomes inflamed, moving your heel becomes painful and difficult. Any actions that put pressure on the inflamed bursa can increase irritation and cause further inflammation and pain.
Bursitis occurs when a bursa is irritated from frequent pressure and it becomes inflamed. When one or both of the bursae (outlined at the top of this page) become inflamed, it is generally referred to as Achilles bursitis because of the bursa’s proximity to the Achilles tendon.
In some cases, an inflamed bursa can become infected with bacteria (referred to as septic bursitis).
Due to the proximity to the area on the Achilles tendon, Achilles bursitis is often mistaken for tendinitis.
Achilles bursitis is a common overuse injury in runners, ice skaters and other athletes.

Athlete
  • Achilles bursitis can happen to anyone – seriously.
  • The achilles tendon handles extreme forces everyday, and the achilles bursae handle the friction from these forces.
  • Achilles bursitis can happen from acute trauma (direct hit on the bursa), but often results from stress due to repetitive movements (running, walking, jogging) as part of your job or from sports related activities.
  • Achilles bursitis becomes more prevalent due to aging as soft tissue around the ankle and bursae become weakened as we grow older.
  • Achilles bursitis is one of those injuries that can really bring down the quality of your life.
  • Anyone – young or old – can suffer from this injury, and if you’re active this condition will keep you from doing the things you love to do. It will definitely interrupting any of your normal daily tasks and make living life harder than it really needs to be.
  • Athletes who over-train or runners that increase their distance too quickly are at greater risk of experiencing Achilles bursitis.

CAUSES

  • Inflammation of the achilles bursae or the achilles tendon usually develops due to overuse, trauma, or degeneration of the protective tissue in the heel and lower leg.
    Specific causes include:
  • Acute Trauma
  • Excess Stress: Uneven distribution of weight will put extra stress on some areas or muscles can weaken
  • Overuse Injury (Chronic) – Excessive friction, or rubbing
  • Improper foot wear, tight shoes or shoes that do not fit properly
  • Repetitive Pressure on the Bursa
    Infection (Septic Bursitis)
Pain at the back of the heel

SYMPTOMS

Symptoms of Achilles bursitis are often mistaken for Achilles tendinitis because of the location of the pain at the back of the heel. When you suffer from Achilles bursitis you will experience some or all of the following symptoms which are most noticeable when you begin activity after resting.

  • Pain at the back of the heel
  • Direct pressure will excarvate pain
  • Swelling, Tenderness, Warmth, and Redness
    Limping
  • May be a firm spongy feeling ( the bursa will appear as a bump, called a “pump bump”, and is usually red, and extremely tender)
  • Weakness
  • Possibly a fever
  • Individuals that wear high-heeled shoes frequently may feel an
  • Increase in pain when they are wearing flat shoes
  • Limited Range of Motion and Weakness
    Untreated chronic inflammation of bursitis can lead to calcification of the bursa.
  • Calcification of the bursa will mean that it will become even more painful than before.

DIAGNOSIS

  • To begin with, you will gather a Medical History about patient and his current condition and symptoms.
  • Ask about the amount pain patient having with his lower leg and heel.
  • How long he have had symptoms?
    if he is experiencing a range of motion loss or limp when walking/running?
  • Details about what caused the pain in the heel?
  • When it started?
  • Whether or not he have ever had treatments for this or a similar condition in the past?
  • Also consider any previous foot/knee injuries or joint stiffness that you may have had in the past. 

 

PHYSICAL EXAMINATION

  • Look and feel the soft tissue and bones in patients ankles to note any differences between the two of them. This will identify any abnormalities, such as swelling, bone deformities, atrophied muscles, redness and/or warmth on the skin.
  • In many cases, the first sign that he has Achilles bursitis is swelling in the back of the foot and ankle pain.
  • Range of motion movements / tests will be done to see how much movement has been lost in his heel.
  • His heel might hurt from the poking and prodding at it, but by doing this the doctor will better understand the source of your pain, the level of tenderness in the area and how well you can move with this condition.

INVESTIGATION


If a soft tissue injury is suspected, an MRI may be undertaken to view where and how extensive the damage is.
An x-ray may be recommended to rule out other possible causes of your symptoms.
Possible causes of pain that an x-ray can identify include instability, abnormal bone shapes (bone spurs or bone cysts), wear and tear on the joints, avulsion fractures (when a fragment of bone tears away from the main bone along with the muscle, tendon, or ligament as a result of trauma), dislocations, arthritis, calcium deposits in the bursa or joint, and/or other problems.

SEPTIC BURSITIS

As the bursae in the heel are close to the surface of the skin, they significantly susceptible to septic bursitis (caused by a cut or scrape) than most other bursae.
One may aspirate (use a needle) to remove fluid from the bursa to check for possible staphylococcus epidermis (or staphylococcus aureus) bacterial infection. Then only you will be able to determine whether there is an infection or not by drawing a small sample of the bursa fluid with a needle.
If it is determined that your bursitis is septic, patient will be prescribed antibiotics to get rid of the infection.

DIFFRENTIAL DIAGNOSIS

  • Achilles Tendon Strain
  • Achilles Tendonitis
  • Haglund’s Deformity (Haglund’s Syndrome)
PHYSICAL EXAMINATION

Achilles Movement and the Re-Injury Cycle

Constant re-injury needs to be avoided at all costs! 


Please excuse the obvious statement, but I really need to drive this point home. Re-Injury is very common… why? Everyone wants to get back to their regular lifestyle once the pain has reduced. Here is where you have to be careful – often, much of the pain is due to inflammation – so, once you iced the area and the swelling dropped, a lot of the pain probably disappeared too. So then you start back at your regular lifestyle and then all of a sudden the old injury starts flaring up again – this is re-injury!


Just Because The Pain Has Dropped, It Does Not Mean The Underlying Injury Has Healed


Re-Injury is bad because sure, it delays the healing process, but what’s worse is that every re-injury and additional healing cycle increases the amount of scar tissue that builds up in the area of your original achilles injury. This applies to muscle, tendons, ligaments and other connective tissue as well.
Scar tissue is a weak form of collagen – hard, inflexible, and tough to get rid of once it begins to take hold. The more scar tissue that develops, the more you lose the range of motion in your ankle. With excess scar tissue build up, the injured tissues and the achilles in general will remain weak and very prone to re-straining and re-tearing.
While you can go a number of days and even a few weeks without any major setbacks during the injury.. inevitably, a certain movement or motion will happen that causes your injured soft tissue to strain and even tear once again. This is attributed to the scar tissue build up and will result in the buildup of yet more scar tissue and a further reduced range of motion (ROM).
The more scar tissue that develops, the greater the risk of winding up permanently injured with chronic pain or arthritis. Scar tissue means that your achilles will not perform as well as it once did and it makes it much more prone to injury later on. The longer the injury remains, the risk of atrophy increases and the risk of more scar tissue increases. This is why it is critical to treat your achilles injury now rather than later.


Continuous re-injury and build-up of scar tissue makes it more likely that you will wind up with chronic pain, reduced Range of Motion or even arthritis (permanent damage).
An Achilles/Bursa Injury Does Not Have to Persist For Months Or Longer. Here is Why It Does For Many:
Recovery from an injury can take a long time, especially when some of the less effective, traditional methods are utilized. This is simply because many treatments either focus on masking of pain or are too inconsistent to provide sustainable improvement. Merely masking the pain is not a solution; it is just a temporary fix.
Doing too much cold therapy will actually inhibit the recovery because you are starving the injured tissues of the blood flow they need to repair and rebuild the collagen. Cold restricts the vessels – reducing the blood flow to the tissues that truly need it most.
The focus on cold therapy treatments should be in the earliest stages of an injury. In the mid and latter stages of a soft tissue injury, cold therapy is used intermittently to deal with flareups of swelling and inflammation.

The truth is, there will always some mild inflammation associated with tissue injuries. However, that inflammation will always remain UNTIL you begin to focus on healing the tissue. Once the tissues begin to heal, the inflammation will then subside more permanently – not just temporarily (as is often the case with cold therapy treatments on chronic soft tissue injuries).
As an analogy, think of a home with a leaky roof. You can place a bucket on the floor of the attic whenever it rains – and this will help temporarily, but does it truly address the situation?
Obviously the answer is No.
Not until you focus on repairing the structural issues with the roof – will the problem be actually solved.
The same concept applies to injured soft tissue – you need to focus on rebuilding and repairing them. To do this, you need more blood flow reaching them, not less.
Achilles/Bursa Injuries Not Only Affect the Ankle – But Can Lead to Other Conditions and Injuries as well.

Every time we use our injured heel, damaged and swollen tendons and muscle tissue move; when they are inflamed, every movement hurts.
With injured tissue, pain happens – sometimes a LOT of pain, so we try not to move it.
Eventually, we use the other joints more and more, instead of having to put the injured ankle under strain again. That is why these other areas start to hurt – they are being overused now.
Soon, aches and pain can become commonplace in other areas of the lower body – all as a result of the original injury and the body’s instinctive nature to “protect” the original achilles tendon/bursa injury – all because the injury wasn’t fully healed in the first place!
We continually re-injure the injury through our daily activities and now this injury has become a chronic injury.

“It is not uncommon for patients who favor one [shoulder] to develop symptoms in the other shoulder due to overuse and overcompensation for the involved extremity.”
In some cases, physical therapists warn that overcompensation can be very dangerous as it will eventually affect gait or alignment on a permanent basis.
An injury to one achilles can easily lead to straining in other areas, making an overall recovery hard to initiate. The longer the injury (and corresponding pain) persists, the greater the chance that you will sustain more strain from overcompensation, eventually leading to issues in those areas as well. To minimize potential secondary injuries, know that it is important to deal with your achilles heel tendon injury quickly and completely.
The faster you truly heal, the less chance you have of sinking into a downward spiral of re-injury, scar tissue growth and overcompensation injuries.

PHYSIOTHERAPY MANAGEMENT

  • Manage the pain, swelling and other symptoms…
  • Use cold/ice pack

If you are experiencing pain and swelling, not only will you use your cold pack for the first 48 to 72 hours after the injury, but you should also use it during other stages of the healing process.

  • After any activity that stresses the achilles in a moderate way.
  • If you have a job that requires you to place some demands on your injured ankle.

However, too many people over-focus on cold therapy while ignoring the most critical aspect to healing – nourishing the injured tissues with a healthy supply of blood flow needed to repair and rebuild injured soft tissue.
This leads to the most important recommendation…
{Focus on Increasing Blood Flow To The Injured Tissue – As This is THE Way That Your Body Will Heal For the Long-Term}

  • Patient Education
  • Release the tight Muscle
  • Remove the aggravating factor/Prevent the further damage
  • Topical /oral NSAIDs
  • Moist Heat/Contrast Bath
  • Stretching Exercises

“NOW LET THE BODY HEAL”

%d bloggers like this: